Hello, and welcome to Night 2 of this Disorders of Consciousness Spotlight brought to you by the AAPMNR. Again, I'm Dr. Craig D. Tommaso, and we'll begin this journey together. We'll start with an overview of some physiatric concepts for disorders of consciousness, especially those that apply to inpatient rehabilitation. We will then transition into Dr. Murtaugh's speech about building cohesive teams and engaging patients and families. And then next, Dr. O'Brien will speak about assessment of consciousness and high-level evaluations. After that, just as last week, we'll go into a case study, where we'll talk about a patient's progress through inpatient rehabilitation with interactive questions, and if anyone has any questions, please speak now. Otherwise, I'll begin the first part of the talk. A little bit about me to set the mood, I guess. I'm the medical director of the Post-Acute Medical Rehabilitation Hospital in Humboldt, Texas. I'm also a consulting physician in the Emerging Consciousness Program, Nexus Specialty Hospital, and the director of Early Career Physician Development at U.S. Physiatry. I do have some disclosures, and I believe I'm the only member of our panel tonight who does. I am on the Speaker's Bureau for Exobionics and for Kindred Healthcare, and I have performed duties for the Advisory Board of Exobionics in the past. All right, so just to kind of sum up where we are, after a severe traumatic brain injury, individuals typically either live or die. Within death, we're including brain death. If they live, however, that person can then be considered either conscious or unconscious. Within that unconscious framework, people may be in a coma, although, as we discussed last time, that's typically thought to be short-lived, or they may be in the vegetative state. If they are conscious, they may be minimally conscious, or they may be fully conscious. And so with this framework, we're going to dig just a little bit deeper, recapping some of the concepts from last time and adding to it. But what do we mean when we say coma? Well, if you don't work in the field or you're unfamiliar, the simplest way to think about this is that there is lack of wakefulness. The person shows no perception, no communication, no purposeful movement that would show that they have any knowledge of themselves or the environment. Furthermore, if we want to be a little more technical about it, and I think last time I used the word scientific, and that was probably not the right term, but technical, if you were to assess the patient with EEG, you would not see a sleep-wake cycle within the brain waves. We think that coma, however, must by definition be very short-lived. Typically, patients then progress to what we're encouraged to call the unconscious wakefulness syndrome or UWS. Old-timers like myself will still call it the vegetative state. Within the vegetative state, we do see evidence on the EEG of sleep-wake cycles. We do not see necessarily signs of awareness of self or awareness of environment, but there does seem to be a sleep-wake switch working within the brain. Minimally conscious could be the next state that the patient progresses towards. Within the minimally conscious state, typically, there are minimal but definite signs of awareness of self or the environment. This may involve some means of communication or attempts at communication, and this may include manipulation of objects in a functional way. Remember that while this seems simple on paper, in real life, this is very, very difficult. In the seminal paper on this by Schnackers and Company, they found that even comparing some of the best experts in the field to the JFK coma recovery scale revised, found that 35% to 45% of the time, the experts were incorrect as compared to the scale. It gives us some thought or some pause that you really need to be careful in evaluating these patients because there may be more than meets the eye. A lot of what we'll talk about moving forward comes from the practice guidelines update. This was published by the American Academy of Neurology, as well as the American College of Rehab Medicine and funded by NIDILRR. When I'm discussing those things in particular, I will highlight them in red to draw your attention. In addition, since that time, the ACRM has also published the minimal competency recommendations or their recommendations of what you need to truly address disorders of consciousness in this population. When I talk or reference those, I'll highlight them in green to draw the difference. First, let's talk about some of the epidemiology of complications after severe traumatic brain injury and when possible, we'll focus on disorders of consciousness. I think there's three lead studies in this field. If you want to look at what the risk of running into comorbidities during a rehabilitation session, you need to look at the Ganesh study, which was done from a cohort of disorder of consciousness patients in rehab at Northeast Ohio. Dr. White's study on reanalysis of the data on the Amantadine study, and I'll include the recent Zane study, of which I was lucky enough to be part of, along with Dr. O'Brien, referencing our cohort of disorder of consciousness patients in Southeast Texas. In the Ganesh study, pneumonia was very, very common, spasticity coming in a close second. As you can see, there were lots of complications and they were all listed there. I would encourage you to go back and look at that if this is helpful to you. One of their key takeaways was if a patient experienced three or more complications during their acute care rehabilitation state, they had a worse outcome at one year, which leads to recommendation 12, which is to make sure that these individuals are medically managed at a high level by individuals who are comfortable managing. Next, if we look at the medical complications that occurred during the Amantadine study, a randomized controlled trial with multiple patients with disorders of consciousness, there was approximately one new complication every two weeks. Again, complications were very common. As you can see, Dr. White broke this into 15 categories, and those 15 categories accounted for more than 60% of the complications that arose. The good news is that with this medical team, the patients got less sick over time. The number of complications decreased over time, leading again to recommendation 12 that these individuals need to be in specialty programs with people who know how to care about them, who are actively looking for managing complications or medical issues. Then finally, in the Zhang study, the level of spasticity was extremely high at 95%, nearly ubiquitous, with pneumonia and UTIs being very, very common. In addition... I'm going to go ahead and mute you, it didn't sound like there was a question coming. Please raise your hand if that was incorrect, I apologize. In addition, significant comorbidities or complications that could obscure the patient's consciousness were relatively prevalent. Let's look at these in a little more detail, and maybe I can give you some caveats for how to approach these issues. Number one, the most common one being pneumonia, which has been shown in all of the studies to be very prevalent. Again, if we look at all of the severe traumatic brain injury, the incidence will run between three and 30%. However, if we focus just on vegetative patients, your white study, it was somewhere between 25 and 48, and in the recent Zhang study, 73% at some point during rehab had a pneumonia. So what are some risk factors, maybe patients you need to be extra careful about? Well, number one, if there's a tracheostomy tube, that seems to be a high risk factor. Swallowing disorders, which are nearly ubiquitous, of course, in this population. Lack of effective cough, which is also frequently encountered in active deep breathing. You may be thinking, well, we'll just put everyone on antibiotics with those kind of numbers. Unfortunately, multiple studies in similar patients, that being severe stroke patients, have shown that using prophylactic antibiotics has really not been effective. So good thought, but probably not your next best move. So what can we do? Well, not in disorders of conscience patients per se, at least it hasn't been studied and published yet, but in critically ill patients in the ICU, stringent oral care has shown to decrease the risk of pneumonias. The good thing is, for most of us working in a rehabilitation setting, at least a setting with other care practitioners, we can include this as part of our ADLs, whether it falls on the nurses, the CNAs, the speech or occupational therapists. In addition, cialorrhea or excessive drooling has been associated with increased risk of pneumonia. The medical answer for that, of course, could be glycopyrrolate or scopolamine, and those certainly can be effective in reducing the cialorrhea. Of course, it needs to be exercised with great caution, because what we're trying to do is rehabilitate these people, and common side effects of both of those medications is sedation. You really need to balance the risk versus benefit for your patient. Another approach could be botulinum toxin to the salivary glands. Subjectively, I will speak to this, and I find that it's often very helpful. I incorporate this in my practice when possible. Obviously, the biggest roadblock to implementing this is funding, botulinum toxin is rather expensive. But there is some evidence that this practice is effective and helps decrease the risk of pneumonia, albeit in other populations. Prophylactic antibiotics have not been effective for urinary tract infections. They're relatively common as well, but it does seem like aggressive mobilization can help reduce the risk of UTI. Again, we're all empowered as physiatrists to try and mobilize these patients early and often, and to hopefully minimize the risk of UTIs through that. And then lastly, pressure ulcers, extremely common, very prevalent in the Zeng study. Risk factors in the literature seem to be internal feeding, low albumin, and decreases in hemoglobin. Interestingly enough, urinary incontinence is not always seen as a high-risk factor, even though most of us, I think, subjectively believe that it is a high-risk factor. So that's something to keep in mind. But certainly, other risk factors play into it. Can we prevent pressure ulcers? Well, there is some evidence in the spinal cord population for electrical stimulation to decrease pressure ulcers. So I think that's intriguing, although typically not what we think of as the first-line treatment. And then secondly, I think a lot of us believe that spasticity management is extremely important for managing skin and preventing or minimizing pressure ulcers. And there is a very nice study done by a poll in colleagues that showed serial casting is a way of controlling spasticity and decreasing the risk of pressure ulcers. Again, if you really want to avoid pressure ulcers, intensive mobilization is important. So as physiatrists, I hope you all feel very empowered to do that. And then the disorder of consciousness, it may look a little bit different than your other patients, but hopefully not that different. We're talking about things like sitting upright, which they usually can do with some assistance. Standing, when we're talking about typically in a standing frame or with other support. Functional electrical activities, such as FES biking. And then my favorite, of course, is just having them walk, whether you do that through a bodyweight, or a treadmill, or a robotic exoskeleton. All right, what about the big ones, the neurologic or medical sequelae that really obscure or confound our consciousness? Let's talk about this for a minute. So the first one I'd like you to think about is contractures. And I know someone out there is probably thinking, boy, I don't think about contractures as being the primary limitation to the consciousness. I'm going to ask you to follow me on this journey for a little bit. Contractures can be severe because they really limit the patient's ability to move and ultimately follow commands, which is what you need to prove if you're going to show that they're conscious. While we don't have a lot of epidemiology available for the TBI population, I can certainly say within disorders of consciousness, it seems to be rather prevalent, especially if they've had a pit stop or two before they end up in your rehab unit. The interventions, of course, are stretching, casting, and ultimately surgical intervention. And once you're thinking in that mindset, think about all the other things that could occur to your patients that would limit their ability to follow your commands or do the things that you're trying to direct them. Think about not only severe contracture, but what about the patients who come to you with severe fractures in your major musculoskeletal? They may not be able to make the movements that they still have in their repertoire after severe traumatic brain injury. Patients can be hemiplegic, both due to the brain injury itself, of course, or subsequent strokes or other injuries that occur afterwards. They can often be paraplegic due to spinal cord injury or brain stem type strokes. There can be peripheral nerve injuries, again, oftentimes due to trauma, but also due to positioning, can be due to faulty equipment, can be due to inflammatory cascade. Especially right now, we're seeing a lot of that with the COVID endemic. Quadriplegia is not uncommon. Cervical spinal cord injury, again, very common in these patients because of the severe trauma they go through. Spasticity, obviously. Again, I would just say, if you look for spasticity, you're going to find it in this population up to 95% of the time, and weakness. Let's stay on weakness for a little bit. You must be thinking these patients, they have a disordered consciousness. How can you incorporate weakness? Well, think about these patients with these severe traumatic brain injuries often have prolonged ICU stay. Oftentimes, it's more than just a brain injury. There's polytrauma, there's injury to other organs. And so it wouldn't be uncommon to share in the sequelae of ICU-acquired weakness and things like that. If the weakness is severe enough, the patient may want to move or may be trying to move, but is simply unable to follow the commands or execute the movement in the position that they're in. The most important thing you can do for these individuals is try and identify where they're able to move. And different rehab groups I've been part of have done this different ways. I think the most effective way, if possible, is to try and use surface EMGs. You can pick up on some of that muscle activity that's controlled, but maybe not strong enough to move a limb or a finger or whatever. Once you pick up on that desire to move something, then you just have to figure out how you magnify that movement and turn it into something that the patient can use, which is relatively easy once you identify it. Going right along with weakness, of course, is spasticity. And again, I believe that spasticity is very common after severe traumatic brain injury, and especially in this sort of consciousness population. Again, you can find epidemiology anywhere from 57% to 95%, so a pretty broad range, but high, right? And I think as physiatrists, this is one of the things that we do best is really treating this. Just so you make sure that we're all on the same page, the armamentarium for addressing this include modalities, stretching and casting, chemo-denervation, and we're talking primarily about the different botulinum toxins there. Neurolysis. I was trained in phenol, but I know people also use other interventions, even cryotherapy. And finally, intrathecal baclofen, which I think is oftentimes very helpful in this population. But putting this all together, if you have someone who already is incredibly neurologically impaired from a severe traumatic brain injury, and then you add on top of it weakness, contractions, and spasticity, you're going to limit their movements. You're going to consume a lot of energy, which they don't have a lot of extra energy to go around anyways and cause pain. All of this will decrease the patient's ability to demonstrate or show what consciousness and cognitive abilities they have left, making them seem more impaired. This is a patient who my team worked with who had really severe spasticity and contracture. And if you look at this gentleman, you can see what an odd presentation it is, how unbelievably twisted he can be. And in particular, I ask you to just pay attention to this right index finger. We're going to come back to that in just a second. Oh, one too many. So again, the next slide is just his legs. And again, you can just see how incredibly spastic, contracted, and weak this gentleman has been with profound muscle atrophy. So the thing to take away from this picture and the thing to remember is if you go back here, this gentleman actually was conscious the entire time. He was so spastic, rigid, contracted, whatever, that he was unable to demonstrate how good he was. And actually, this right index finger here was what he ended up using to indicate yes and no and to spell out and write words once we were able to loosen his arms and legs and hands enough that he could actually move them again. So while he came to us looking very, very low level, in fact, a lot of it was just, one, fatigue from being so spastic, and two, inability to really control the spasticity and contracture to make meaningful interactions. Thought it was a neat study, and I wanted to showcase it to you as how those things came together. Moving forward, we talked just a little bit earlier about profound weakness. And think about the most extreme version of that, the critical illness myopathy that often develops in the ICU. So critical illness myopathy is thought to be a response to severe systemic inflammation that occurs during ICU-type care. It can severely impair motor function and cause profound weakness. In our recent study, we found 6.2% of our population had it. And if you look at all ICU patients, again, depending on the cohort, the ICU and the subtype of the population ICU patient, somewhere between 25% and 83%. There is an EMG nerve conduction study criteria for diagnosis. So if you're an electromyographer and you're doing this in the ICU, you may be able to make this diagnosis there or when they first present to your rehabilitation. Similarly, muscle biopsy can be used to diagnose it, although this is not typically the intervention used. And CK may or may not be elevated. So if that's helpful to you, it could be there, but would not be required. Typically, however, this diagnosis is made based on a clinical examination. Things in an able-bodied person that would make the diagnosis would be proximal weakness worse than distal weakness, abnormal sensation, sorry, typical normal sensation as the myopathy, focusing on the muscles, not the nerves, profound muscle atrophy with preserved facial strength. So you're looking for just wasting of the muscles. The literature would indicate that it typically takes sometimes more than 24 months to recover. So you have to be very patient with these individuals. And there is a lot of work being done. You evaluate early mobility to see if that can assist in some way. However, the results up to this time, at least, are very mixed. So while we're very hopeful that early mobilization can help to minimize this critical illness myopathy, I think we need to keep a little bit of skepticism because the results have not been overwhelming at this time. The sister of critical illness myopathy, of course, is critical illness neuropathy. And I've separated them out, although oftentimes, of course, they occur together and overlap quite a bit. The pathology of critical illness neuropathy is, again, related to that systemic inflammation, this time damaging the nerves instead of the muscles. And part of the sequelae of that, obviously, is that you have decreased function for both the muscles and the sensation. Again, epidemiology is around 6.2% in our most recent study. And again, there is an EMG and nerve conduction study criteria for diagnosis. You could also use a nerve biopsy, although this is rarely done. So again, the physical exam is flipped a little bit. You're looking for the weakness now more distal, even proximally, because it is a length-dependent process, so longer nerves are more affected than short ones. It is accompanied by a new pathology study and it is accompanied by sensory deficits, by definition, because you have nerve damage. And there are oftentimes neuropathic pain complaints if the patient can't communicate to you. But once again, facial muscles and sensation is typically spared. Recovery takes a while, and while we continue to hope for early mobilization to make a difference, the evidence remains unclear. Okay, so while we're thinking about disorders that limit the patient's ability to move, what about things that limit their ability to understand the stimulus you're getting them when you take them in? I think things that need to be on your radar include aphasias, which are not uncommon in this population, obviously, as we're dealing with brain damage and oftentimes accompanying strokes. Hearing loss, which again can occur either premorbidly or due to the trauma itself. Sequelae from facial and cervical trauma, which is not uncommon in this population. And of course, tracheostomy, which limits the ability of the vocal cords to communicate. So aphasia was somewhat common within the most recent study by Zhang. And it's difficult to diagnose though, right? Because it's disorder of consciousness by definition, these patients are not up and walking and talking. So how do you filter out that aphasia? Well, number one, I think the patient isn't communicating, you're looking for right-sided weakness and spasticity. Given the normal architecture of the brain, typically left-sided brain damage will cause both aphasia and right-sided weakness together. So those things can run together. Sometimes there's a clue on imaging as there may be hematomas or a cluster of DAI within the left hemisphere, which again may predispose you to aphasia. And finally, facial expressions or movements, things that the patient is trying to do, but limited due to aphasia. And sometimes this can be filtered with what we call an IQBA, which Dr. O'Brien will cover in much more detail later tonight. Other things that can kind of impair the patient's ability to interact with you. We talked a little bit about hearing loss already. Think also about those hemiplegias and paraplegias, of course, peripheral nerve injuries, polyneuropathies, neuromyopathies we've covered now, quadriplegia, and then vision deficits, right? Patients can be blind. Obviously the first thing that comes to mind is trauma to the eye or the globe itself. They can also have vision loss, whether it's from damage to the globe, herniation, which can impinge or damage the optic nerves, or even cortical blindness often associated with anoxia. In addition, if the patient is not responding the way you want them to, sometimes it's simply because they don't have enough energy or they're not around. Think of if you were ever in college, perhaps one of your roommates would go out and have one too many drinks and not have their morning coffee. It would be very difficult to arouse in that state and sometimes bothersome. In the same way, your patient may not be able to give you their best effort because of other things that are affecting them. Common agents here are medications. Listed a couple of different categories for you. Of course, all of these medications are not uncommon in this population, so you need to spend some time kind of filtering out what you can and what you can't. We talked a little bit about that at our previous night, and we'll talk more about it tonight. Severe pain certainly seems to decrease general arousal and limit the patient's ability to interact so much so that treating pain is one of the recommendations from the AAN and ACRM. And then lastly, sleep disorders. And just a few seconds talking about that. So we really don't have much evidence on sleep disorders within the disorder of consciousness population. However, within traumatic brain injury, we do have a little bit of evidence and some research that was done on sleep disorders, so we'll try and extrapolate that as much as we can. I would say within this population, I would just stress that I really feel polysomnography has to be the gold standard, right? These patients are not going to be able to contribute on a questionnaire or to fill out a survey. Their loved ones may or may not try and extrapolate their observations as best they can, but polysomnography, when possible, would really help to clear the diagnosis. So if we look at intrinsic sleep disorders that seem to be fairly common within research in severe traumatic brain injury, things that have been reported include central sleep apnea, obstructive sleep apnea, periodical and movement disorder, narcolepsy, and circadian rhythm disturbances. We'll talk a little bit about each one. So central sleep apnea is often accompanied by insomnia or excessive sleepiness, and this is really the definition of it, though, is frequent shallow or absent breathing during sleep. Patients, well, not patients in this case, but family members may report things like gasping, grunting, or choking at night, body movements, and possibly cyanosis. Again, polysomnography is really the best way to diagnose this. Obstructive sleep apnea is certainly a little more common in the lay population. We've got the central nervous system damage, hopefully. The average person is more at risk for obstructive rather than sleep apnea. Again, it's often accompanied by excessive sleepiness or insomnia, and the pathology, of course, is obstructive breathing. Things that the patient or family may report would be loud snoring, morning headaches, dry mouth upon awakening, and severe chest retractions during sleep. There are a few different ways to diagnose this, but again, I'll just stress polysomnography is the gold standard. Periodic limb movement disorder has been well categorized after traumatic brain injury. Again, it is accompanied by insomnia or excessive sleepiness. See how you can't use the symptoms always to diagnose these things? But the real pathology is repetitive, highly stereotyped limb movements that occur at night and limit the ability to fall asleep or wake the patient up from a sleep and interfere with normal sleep cycle. Again, a good polysomnography will diagnose this. You can also get there, though, through actigraphy. And finally, narcolepsy, or as some people call it, after traumatic brain injury, post-traumatic hypersomnia. So this is relatively benign in that it continues to be... Benign is the wrong word. This is, once again, following our trajectory here, that all of these present with the same complaints, excessive sleepiness. The difference is, of course, not in disorders of consciousness patients. They simply look more unconscious than they need to be. Polysomnography, again, can help diagnose this. Other people use the multiple sleep latency test. And circadian rhythm disturbances. So you'll hear a couple of different terms for this, non-24-hour sleep or sleep-wake cycle syndrome and things. Again, the complaints are typically similar, and it's the inability to maintain the 24-hour sleep pattern. Again, you can get there with polysomnography, or you can use continuous monitoring via actigraphy. Okay, so what do we do with all this information? Well, based on the severe traumatic brain injury, we have to imagine that these sleep disorders are affecting our EOC patients. So what do we do next? Well, for narcolepsy, there may be an abnormality in orexin or hypocretin. So if you're in a large academic center, perhaps you can send off for those studies. Although we know that methylphenidate is a relatively helpful neurostimulant. It could be argued, although I'm not saying that you have to do this, but it could be argued that you need to treat empirically if you have any concern for narcolepsy in this population. For obstructive sleep apnea, or even central sleep apnea, sometimes if family or nurses are especially observant during night, they may be able to give you the clues. But as I've hopefully beat into your head by now, I really think you need to try and get polysomnography if and when you can, when funding allows. And then finally, circadian rhythm disturbance. I think this is really common, although I don't have a lot of evidence to back it up within the DOC population. These individuals are typically not exposed to light, kept in ICUs for a long period of time, and they really lose any kind of external stimuli that might help them regulate their sleep-wake cycle. So you almost have to imagine having a severe traumatic brain injury and going through that process in our modern medical system is a good setup for circadian rhythm disturbance. On my DOC patients, I always request that they get at least five to 10 days of empiric melatonin to kind of reset their circadian rhythm disturbance. I also request that my therapists take them outside whenever possible so they can get some of that sunshine and vitamin D and hopefully reset any circadian rhythm disturbance that is present. Just an idea to give you some background on this. This is one of my favorite studies. It was done by Dr. Castriotti here in Houston, Texas. We took 57 patients who had had different severities of brain injury and tested them all with polysomnography, regardless of whether or not they reported they had sleep issues. Surprisingly, a large number did not. A fair number had obstructive sleep apnea. A small number had narcolepsy and periodic limb movement disorder. So just to give you an idea, they're out there. The patients may or may not be aware of them. You've really got to have a high index of suspicion for these things. And again, we talked a little bit about the treatment, CPAP and BiPAP for obstructive sleep apnea, Tamiprexol for periodic limb movement disorder, melatonin light, and exercise for circadian rhythm disturbances. And if you think there's a general anxiety, insomnia type thing, NSSRI would probably not be the worst idea for these patients. All right. Once you've done those basics and you've tried to rule out the comorbidities and medical complications, how do you begin doing some basic rehabilitation with these patients? Well, let's jump into that. So the gold standard at this point in time has to be this minimal competency recommendation from the ACRM. It's expert level of evidence on what to do and how to build a program and what you should be offering at the minimum level. It doesn't mean you can't do more, but if you're really going to be serious about treating these patients, it's a nice minimum. Number one, we've talked a lot about the complications and medical comorbidities that can exist. You've got to have a way of preventing those. So this is kind of a checklist for you, which the recommendations recommend, of things to go through and think about how your program will minimize these kinds of complications which occur. Hopefully you appreciate now. Next, you've got to stimulate them and offer them treatment. From my perspective, this breaks down into three major categories. Number one, sensory stimulation. These patients need stimulation. All too often, they're rather neglected or under-stimulated within the ICUs. So think about how your team will give them auditory, tactile, and even olfactory stimulation to help them wake up and engage. While I agree there's very, very little evidence regarding these interventions, there is probably no harm. And I think that they are important to enrich the environment and stimulate these individuals to engage and do more than they're doing. Next, physical rehabilitation. Although we have not significantly changed consciousness per se based on physical therapy, I think we all agree that it's important for mobilization. I think it's important for trajectory, for battling the deficits that occur with immobility. Furthermore, a few different small research studies, and I apologize if they're not cited here, please contact me outside of here and I'll send you the citations if you like, have indicated that the more time that patients are standing, the higher the likelihood that they will make progression through the disorders of consciousness. And then intensive mobilization can be lots of things, as we talked about earlier. It doesn't have to be groundbreaking, right? Having one or two therapists support the patient on the edge of bed is a great way to change their level and to mobilize them a bit. If you have the resources, certainly dependent standing with say like a standing frame, FES activities like FES biking is relatively common. And then I will always support walking these patients. I think it's incredibly helpful, whether it's through a body weight supported treadmill or robotic exoskeleton. I think it would be a little bit cruel to ask your therapist to do that as to physically carry these patients can be overwhelming. And here's a slide I stole from my colleagues at Baylor Scott and White in their disorder of consciousness program. And it shows a gentleman within an exoskeleton with a headstrap device for head control and he's being mobilized as you can see here by two or three therapists. This slide on pressure ulcers and spasticity management probably belonged earlier, just indicating that aggressive spasticity management can minimize the risk of pressure ulcers just like mobilization. Maybe that's why I included it here. All right, moving on, we'll talk about neuromodulation for these patients, and I think this is, again, something you'll address if you're dealing with the disorder of consciousness population. So when let's talk about pharmacology, and when we talk about pharmacology, we have to talk about imantadine, right? We have probably our best studied intervention in imantadine. It was done in the Giacino and White study that was a randomized controlled trial for patients with disorders of consciousness, and it showed significant improvement for the patients who were on imantadine as opposed to those who were on the placebo intervention. It had improved rate of recovery, and of course, it was a strong medication effect in that they improved on the medicine, and when it was stopped, the placebo group caught up. It also seemed to help patients progress through the stages of recovery as fewer patients were in the vegetative state after the medication, and again, this was largely driven by increased performance on behavioral testing. And here is the key graph from that study. As you can see, the top chart, the slightly less gray line, if you will, is the placebo group, and the dark gray line is the imantadine group, and as you're probably familiar with on the DRS, the lower the score, the better, and so the imantadine group was slightly better but not statistically significant at time zero. It did remarkably better on the DRS than the placebo group until week four. At week four, the imantadine was stopped, and so then both groups continued no medication, and there was some regression of the imantadine group, not really regression but plateau perhaps to the same level as the placebo group, indicating that it probably was the medicine that made the difference as they came back to similar non-statistically significant scores once the medicine was removed. Here again, I think a very important figure from that publication, you can see the different tasks that the patients were asked to do, and you can see the dark blue line is the performance of the imantadine group, the light blue line is the placebo group, and on almost every task, the imantadine group outperformed the placebo group. There are some critiques of this study, of course. I think the major ones are that, number one, the imantadine group was very slightly less impaired before the medication was administered, although it was not statistically significant. Perhaps that played a role. And then two, of course, the effect wore off once the imantadine was stopped, leading some to argue that the imantadine did not cause a significant recovery, it simply improved performance. Being a physiatrist, so long as the patient's doing better, I don't really care, but I know that that bothers some people. Talking about pharmacology, of course, we also have to mention zolpidem. About one out of 15 patients in the vegetative or minimally conscious state has a profound improvement in their performance with zolpidem. The exact mechanism is thought to be unclear. It may be an inhibitor of an inhibitor somewhere in the subcortical area. Other people have also postulated, perhaps, that these are patients who are limited by catatonia and we're unmasking the catatonia, so the patient's doing more. But the profound when it's reported, the effect when it's reported, is typically profound or noticeable. It's a large effect. For most of the patients, I'll say, nothing's 100%, but if they have a response, it's not something that you're going to have to search for. It's going to be pretty obvious to you, to the family, to the therapist. Again, if we think of our recovery, we're looking at patients who start here, comatose, quickly progress into vegetative state or minimally conscious state with the motor responses occurring quick before cognitive capacity improves. Once they become minimally conscious, we hope that their cognitive capacity then starts to improve as they go through severe disability, moderate disability, and eventually recovery. I would just encourage you, as we talked about last time, please be patient with these patients. We've seen that good outcomes sometimes take five, even 10 years. If you work a comprehensive program, if you're able to address things in a systematic way, minimizing the complications, they do typically get better, but you really do have to have a lot of patience with this population because it can take years. All right, I've left you some references. If you need others or there's something in particular you want to discuss, please contact me after or outside of this presentation. On that note, I will turn it over to Dr. Murtaugh. I am going to turn it to Dr. O'Brien first because I think her content will then lead more effectively into my content on interdisciplinary care and care planning, so I'll turn it over to Dr. O'Brien. Hi, everyone. I'm Katie O'Brien. I am a clinical neuropsychologist by training, and I work at Tierne Memorial Hermann in Houston, Texas. I'm really happy to be here to share some of this information with you all. I think there's a lot of area for physiatrists to make a big impact in this population, so I'm really excited that this was an area of spotlight for the conference. I don't have any disclosures, and kind of jumping off of what Dr. Rosenbaum taught last week in terms of standardized assessment, I think it's important for us to go above and beyond just what has been standardized given these patients are so individualized, so that's really where I'm going to spend a lot of the time today, and we will go from there. So, first, as Dr. DiTomaso even started with, we have guidelines to go off of, and the big push right now is when you create guidelines, how do you ensure that the implementation occurs? So, the AAN guidelines on the left, those were published in 2018, and what we find is that not many places have instituted the recommendations, including some of the more simple recommendations, as in using the word chronic instead of permanent or persistent, and other things that you heard about last week when we talked about it, so there's a lot of work now in knowledge translation and implementation science to try to push these through. The minimal competency recommendations in the middle have come out, and those have a nice checklist for people who want to say they'll treat this population, giving you the ability to kind of make sure you're meeting at least the minimal standards, and on the right, you'll see the European standards for treatment of disorders of consciousness, and those do vary a little bit from what we have here in the States, and it does make a difference based on our different healthcare systems, so I'll go over some of the specific few guidelines that are relevant to behavioral diagnostic assessment. The recommendation two talks about arousal and increasing the arousal before performing these evaluations. The most important thing to think about is these patients have been in bed, they're supine, they're not being put in different positions, so we heard Dr. Guitemaso talk about that, and when we're talking about consciousness, we have to know the difference between arousal and awareness, so arousal is the level of alertness and does not imply consciousness, so it's necessary but not sufficient, and awareness is of the environment that constitutes the consciousness, so you need both to actually be considered conscious, and arousal, we can make a big difference on both as therapists, as providers, and then from a psychopharmacological standpoint, but again, as I said, these patients are frequently left in their beds, in hospitals, in positions that don't promote awareness or arousal, so it's really important that we work on those sleep-wake cycles, we're turning the lights on during the day. Recently we were fighting with a family member who insisted on low stim, but we talked about the importance of sleep and sleep hygiene, so we still kind of push for the lights on and windows open during the day, it does make a huge difference for these patients, and so I have a short video clip here, and what this shows is the arousal facilitation protocol. This is part of the CRSR that Amy talked about, when you're testing the patient, there's a standardized protocol where you roll the patient's muscle bellies between your thumb and forefinger, this is to increase their arousal, there's no point in asking patients to do something and to determine their level of consciousness if they're not awake, so this is very important, now this is an older video where the protocol started on the face and worked all the way down one side of the body and then proceeded to the other, the most recent update actually just works with the face, the neck, the SEM, and the shoulders, so I find that that is helpful for sustaining arousal. So when we're talking about behavioral assessment of these patients, we're talking about performing serial assessments, we're talking about multiple examiners, it's not okay to go in and just have one person try something and make a conclusion based on that, we're looking for people who have experience in DOC to look for those little nuanced behaviors, and I will kind of call myself out here as a neuropsychologist in training, when I was on my internship and my supervisor would give me a list of patients to go see on the unit in the morning, I would walk into patients who were in a DOC's room and I would look at them, kind of try to interact with them, I wouldn't really get anything, wasn't getting eye opening, tried to hold them open, tried to ask for command, nothing, I would educate the family, say the patient was, you know, somnolent, and say I'll be back when they can do more, but at the time I didn't know what I didn't know, so I didn't know all the things I could do to look for different behaviors that indicated different levels of either cortical functioning or more brainstem reflex, so it's really important to know these things, it's important to try different times of the day, it's frequent on the team that you'll hear about with Dr. Murtaugh later, that you may assess a patient at one minute and the next minute they look completely different, variability is part of the game in this population, and how do we increase the performance and minimize the variability while improving this patient's functioning? We want to do the assessments under maximal arousal, we want to include family input, this is really, really important, and the reason is, is families know these patients best, many of our families that come to us labeled as difficult families are frequently the ones that are spot on and correct about their loved ones, I actually find some of our families actually question our kind of conclusions, hey this person can follow commands, are you sure, how do you know that they're not just spontaneously moving, more so than over-interpreting what their loved one can do, so it is important to include the family input, there's also literature to suggest that if the family participates in the assessments or is even just in the room, the patient performs better, so it's important on the coma recovery scale that Dr. Rosenbaum presented about last week, there's a component of the test where you're asking to see if the patient can localize to a sound, we frequently have the family member call the patient's name or try to get them to localize because they're far more likely to localize to their family and loved one's voice than ours, and lastly accounting for confounds, and Dr. DiTomaso has reviewed some of those, I'd like to talk about a few more from a behavioral standpoint that are important to take into account, so recommendation 2D talks about identifying and treating these conditions, but also taking them into account, so every single thing listed here can impact the outcome of your assessment, and I want to give you some real-life cases that I've encountered that have really thrown the clinical team through a loop, so hearing deficits, if you have a patient who somehow becomes deaf, whether it's through trauma, they started with sensorineural hearing loss in one side from birth, that patient will potentially look minimally conscious, we had a patient where the wife was telling us, I think he can follow commands, but for some reason he was really only doing it for her, and while we know, you know, they're more likely to do it for a family member, we couldn't figure out why, and what it boiled down to was he was reading her lips, and he was far better at reading her lips than any of us, because he had never met us, so he was following her commands much greater than ours, and as soon as we started writing down our commands on a whiteboard, he was doing everything, so being able to know whether these confounds are impacting your assessment is important, having an aphasia, a primary language deficit, so they're not going to understand what you're doing or asking them to do, so you think, okay, well, then why can't they mimic me, right, so if they don't understand what's coming out of my mouth, why can't they just do it if I show them what to do, well, what if they're aphasic and apraxic, so they have the motor planning and coordination difficulties as well, you tie a few of these together, and a patient can look completely unconscious when in fact they're there, so being aphasic, apraxic, potentially cortically vision impaired, these are all things that can severely impact your assessment, and getting the level of consciousness right is very important, because people make life and death decisions based on what you say, so we spend a lot of time looking at each of these and how we can overcome or how we can look at how this may impact the outcome so that we can make those, just help families make those decisions going forward. Here you'll see some of the same pictures that Dr. DiTomaso shared with you, but again, positioning, posture, getting them in a good place for them to be able to show us what they can do is one of the most important parts of behavioral assessment in setting these patients up for success. If they are so severely conjectured they can't show us, then we're going to be wrong all the time. The other important thing is getting these patients into different positions and different environments, so the patient on the left, this is one of my favorite pictures ever, and what you'll see is a patient who had a very hard left turn preference with her head, and we placed her brand new grandbaby on her shoulder, and the baby was crying, and the patient turned her head very quickly to localize to the baby. In addition, what you'll see is on the left arm, they have, they're looking at surface EMG to see if they can get activation of the arm, so at times the therapist would lessen her hold on the baby to see if the instincts of the grandmother kicked in to hold the child. This is meaningful, it's salient for the patient, and we find that when you put these patients in these situations, you see things that you wouldn't have seen otherwise. The patient on the right, again, these patients have been in bed in a long time, putting them in different positions really changes what you will see. My favorite is the residents on our services coming in, confidently reporting in rounds that these patients aren't following commands, they're not doing this, they learn very quickly after being on the rotation not to say those things very confidently and more to ask your team, what are you all seeing? Because they realize as soon as they say all those things, the team is going to tell you all the things the patient's doing for them. So again, you'll hear a little bit later about the team approach, but I think it's really important to put these patients in different positions. Now, most importantly, one of the things I wanted to focus on today is the individualized quantitative behavior analysis. Now, this is not something I want to talk about because I think you should turn around and be able to implement this wherever you work, but I want you to really think about this process and how we come to conclusions about what a patient can and can't do without potentially getting all the information we need. So Dr. John White published this in 1999, so it's not a new process, but it's not used as much as I expected to, and I know at least on our unit, we use it fairly frequently to determine and be able to answer questions, and it's just a process of creating an end-of-one experimental design to answer specific questions. This is used complementing the CRSR or other standardized scale, and it really looks at the frequencies of behavior using statistics to allow us to determine more what a patient can and can't do. This is a sample IQBA. So in this situation, what you can see is we're measuring whether a patient can move their left arm, and on it, there's three different conditions, and we're going to go over why there needs to be three conditions. If I were to ask you without, you know, if you knew this wasn't about not having enough information, and I said, how do you know if a patient can follow commands? The number one answer I get when I teach the residences, I go in the room and I ask them to do different things, and the go-getters will tell you like, oh, and I set them up for success, and I tried to reduce gravity, and I did this, and I, right. So how do you know that they could follow the command? Well, they did it when I asked them to. Okay, but how do you know that that wasn't spontaneous? Now, if they held up two fingers, pointed to the ceiling, and then pointed to the floor, because that's what you said, sure, I'll give it to you. They're conscious, but what if it's a simple behavior because everything else has been taken away by the impact of the injury? So lifting the thumb, maybe the thumb moves spontaneously every once in a while. You'd be surprised if you just watch people, their thumbs move. So here's an example. John, lift your thumb. 49 times he responds and 48 times he doesn't. So I'm going to ask for responses. We'll see if anyone's paying attention. Just yell it out. Can John follow commands? He has a 51% response rate. Yes or no? Can he follow commands? It's okay to say I don't know as well. Y'all are going to just make me talk by myself the full time, aren't you? Okay, we'll keep going. So yeah, so can John follow commands? I don't know. Here's where I'm saying we need more information. We need to know more than just asking John to lift his thumb, okay? Why? Because what if I told you I also collected data asking John to hold still, okay? So now I asked John to lift his thumb. He lifted it 49 times. He didn't respond 48 times. I also asked John to hold still. 40 times his thumb still went up. 57 times it didn't. So let's all assume you guys had in your head what your answer was when I had this slide up. So you either said yes, absolutely. John, command following of the year. Give him the trophy. He can do it. Or you said, no way. 50-50. He can't, right? Or you said, I don't know. Is this a trick question? Are you trying to fool us? Whatever your answer is, does this data now that I told you John's thumb still went up 40 times when I said to hold still, does that change your thoughts on the first page? So maybe you were in the team that said John's winning command follower of the year, and now you're like, hold up. Let me pump these brakes. John's lifting his thumb even when we say hold still, okay? So maybe this changed what you were thinking. Now look at this data. What if the data looks like this? Now John lifts his thumb 49 times, like I said, but when I asked him to hold still, he only lifted his thumb 12 times. If I were to run a chi-square here and compared the command condition to the contra-command condition, the hold still, this is significant. What this tells me is John is treating lift your thumb differently than hold still. This tells me John can follow a command, right? But the previous slide tells me nothing. He's not, if I run a chi-square here and compare statistically the two different conditions, he's the same. So this actually doesn't tell me anything. This gives me more confidence to say John can follow a command, even though about 50% of the time he's not going to do anything. So if I go in, it's possible because of statistical probabilities that every single time I walk into John's room and ask him to lift his thumb, he does nothing. It's possible, right? But again, we don't have all the data. Here we see the third condition. If you're assessing a command in someone who has a minimized kind of repertoire of behaviors and potentially some spontaneous movement, whether it's tone associated, whether it's myoclonic, whether it's some sort of akathisia or restlessness, whatever it may be, you may have to find the signal in the noise or even a signal with not much there. So you need the three conditions to be able to identify if John can follow a command. So now, if you guys were like really excited to answer before, now I really want to hear you. So with the three conditions, if I told you that I asked John to lift his thumb and I gave him 10 seconds to respond, 49 times he lifted it, 48 times he didn't. I told John to hold still, 40 times his thumb still went up, 57 times it didn't. Then I observed him with no interaction for 10 seconds, 12 times his thumb came up, 85 times it didn't. What is my conclusion? Can John follow command? We have one yes in the chat. Thank you. Okay. Another yes in the chat. Okay. So these people are on team, go John, you can follow command. That is, so when the data looks like this, where he treats the command in the contra command the same and his thumb doesn't lift that many times in the third column, the observation, John is inherently treating these conditions differently than no verbal input, but the two verbal conditions are treated the same. In this setup, you can see he treats column one differently than column two and three. So John can follow commands here because the command is different than the contra command or the observation. But in the previous set of data here, I can conclude that John definitely does something when I ask him to do, when I verbalize, but I don't think he's understanding what I'm saying. So John might be a phasing here, but without having all three conditions, I could actually inaccurately say right here, John can follow command and think he understands language. When in fact this might be John and he may be completely globally aphasic and he may just be lifting his thumb more when he hears my voice, but doesn't understand a word of what I'm saying. So again, this is a strategy to help find patterns in behavior that we frequently miss as providers. If we just go in at bedside and say, Hey, show me two fingers or wiggle your toes. And this is something that I try to instill in a lot of the physicians that I've worked with and trained is that we have to do more for this patient population because they are so muted in terms of their behavioral responses. And this is why this is a good adjunct to the standardized CRSR assessment. So in terms of the IQBA conclusions, command following is one aspect used to assess consciousness. We've actually had an IQBA find consciousness prior to the CRSR in a handful of patients. And the reason being is if a patient can do something, even if it's only 10% of the time, right? Even if it's the smallest percent, but they do it that many times, they're conscious. The CRSR, the bar set for that standardized measure is for command following is 75%. So we're taking a patient population that has all these compounds, all these medical implications and complications and things that can mimic disorders of consciousness and they're on a lot of medication and we're asking them to do something 75% of the time, they don't typically do that. So having a standardized assessment that allows them to show that they're conscious with a much lower response rate is really important. I also tell the staff all the time, wouldn't you rather have a patient who responds 10% of the time, if you know they're 100% accurate, than responding 100% of the time and being 50% accurate, right? So I think that makes sense to us, but sometimes when I tell my nursing staff, they said, well, I asked him to move his arm in for yes and out for no, and he moved in and that's his yes, so he was in pain. And what I tell her is, you know, he moves all the time. It's not always reliable. So again, we wanna be able to give the percentage of what's the response rate and what's the accuracy rate. And again, we want the accuracy rate to be the higher number. Obviously we want them both high, but it also helps facilitate family members understanding. So when you have statistics and numbers and you can show the family, this frequently helps one with buy-in, and two, I can't tell you how many family members will create a communication system and the patient's doing fantastic with it. And we come in and the family's using eye blinks or some, oh, when he does that, that means yes, or when he does that, that means no. And trying to show them why their interpretation of whatever behavior it is, is not accurate, is sometimes better done through numbers than just saying, in my opinion, we shouldn't be using eye blinks. So it's really helpful to have that statistical means, and this is not hard. We're just human, and so we're biased. I did my own little kind of study one day, and I sat in on several of our therapist sessions, and I counted how many times the therapist would give a command and how many times the patient actually responded. And then I went in and audited all their notes, because we as humans don't realize how frequently we ask and how we remember the times they respond, right? But we don't remember all the times they don't, so we are biased inherently. Another thing that you can set up using this type of protocol is a vision protocol, and this is really important because our visual system is what we really rely on in rehab. How often are our therapists demonstrating, showing a patient, moving them throughout, expecting them to know where they are, where they are in space? Hey, lean over here. Well, where's here? So vision is really important for us to know, and a standard neuro-ophthalmology exam is really limited. So I can tell you, at least in the hospital I work in, early on in the course of DOC rehab, if we consult our functional vision team, it's really for ocular health. It's not for clinical diagnosis of vision. These patients frequently come back with one diagnosis, and that's cortical vision impairment. And what I like is that we say cortical vision impairment and not cortical vision blindness, because that's what we used to hear all the time. And we'd have patients who were clinically able to spell using letter boards, and functional vision would say they're blind, and the families would then come to us very confused. So clinically, we're actually able to find vision better than sometimes a one-time neuro-ophthalmology assessment. So this is set up similarly to a command following protocol, and it's pretty cool. And I'm gonna give you guys like a really quick heads up. I'm gonna ask another question coming up soon, so get ready. So the first thing you do is you take kind of a blank card, and then you take something meaningful and salient. So it's frequently my favorite, the family pet, or a picture of the family, or the baby in the family. But you have a very meaningful, salient picture, and you have a blank card of the same size. And the procedure is you just hold them up in either a bilateral condition or a unilateral condition, and you record which way the patient saccades their eyes within the first five seconds, and then you move to the next condition, and there's six total conditions. So you have the condition with the blank card unilaterally on the left, and then the right, the meaningful, salient picture on your right and your left, and then you have the bilateral condition where you have the card and the picture on both sides. Now, here's some data. This data is put in order. You would typically administer this in a randomized order. So you wouldn't administer it in this order, but it would be administered randomly. And if you look at the data, this is the data accumulated over several different administrations. And this data is all from the white 1995 paper. I'm more than happy to send anyone this reference as well. And what you see is in condition one where the photo is presented to the patient's left. The patient looks left nine times, looks right one time, and no response 21 times. And you can see that all the way down. So what are my conclusions just solely looking at this data here? What can I say about this patient's vision? Anybody? I'll give you a hint. I don't know if you can see my cursor, but I'm pointing to the hint right here. Chomping up a bit to tell me that this patient has a right visual preference, right? So this patient looks right significantly more than he looks left, right? Frequently when given the opportunity looks right, look at that 89 times versus 28 times. And in this unilateral condition, there's a strong relationship between the side of the stimulus and which way the patient orients. Now, what I want you to do is compare condition one to condition five. In condition one, when the stimulus is presented only to the left, the patient looks left nine times and only looks right one time. In condition five, if I'm holding up a salient picture and a blank card, we as humans are always going to look at the salient picture first because it's more interesting. But if you look in condition five, the patient actually looks at the card 25 times and the photo only once. So, all right, get ready for it. It'll be, I'm going to give you two choices. So you can get it wrong, but 50-50 shot. Does this patient have a left field cut or a left inattention? And can you tell from this data? Anybody, throw it out there. Yes, yes. Okay, that person gets bonus points. Left neglect, this is a left inattention. So when there's a competing stimuli on the right, the patient loses the salience of the left. But if there is nothing competing, so in the unilateral condition, the patient makes their way to that picture on the left as in condition one. So this is a way for us to identify an inattention versus a neglect without the patient being able to communicate with us. And it's very robust in terms of getting us that information. Thank you for playing along with me on that one. So a patient who behaves inconsistently is really the most difficult to assess. A few observations, it's not enough to make a conclusion and we have to control these conditions to guard against different things and other confounding factors that may present and challenge our ability to make a conclusion with this. Very quickly, one of the reasons assessment is so important is because leveraging this into a communication strategy is one of the highest priorities in rehabilitation. One of a former patient, one of the things that I really has stuck with me was a family member who said to me, if all you're gonna do is get them to blink for yes and no, blink for yes and no, they would never wanna live like that. What's the point? That's not worth it to us. This patient came in labeled as vegetative, hadn't seen anything, got to us. We assessed the patient, we worked with the patient. We were able to leverage their movements into a communication system. And so now they weren't blinking because that's not what we like to do, but they were moving their arm in for yes and out for no. Typically, when we do this, we like to do it in the gravity eliminated plane. So as you can see in that first picture, whether it's overhead fling, whether it's a mobile arm support, whatever it may be, but this patient then was able to answer yes, no questions. That family member did a full 180 and said, if we got them nothing more, it was 100% worth it and life was worth living. And that their loved one would totally wanna be alive. Now, obviously that contradicted everything they told us in the beginning, but I think communication holds that much weight and is that important. So getting it right is important. So when we're looking for communication, we're looking for two different movements or visual indicators of discrimination. So it's not okay to say, hey, lift your hand for yes and don't move for no, because how do I know they're actually saying no or they're just not responding? So we need two movements and you need to be creative. So the patient in the mobile or the arm flings, as you can see on his wheelchair, we actually put visual indicators stuck into the phone where he can see the yes and no and move his arm towards them. The patient in the second picture, it's a little bit hard to see, but he actually has a laser pointer, one that could be either used if you're presenting in real life or if you're tormenting a cat. It's actually Velcro to the top of his head and he's using it to point to different things on the board in front of him. And this has been found in a lot of our patients that don't have good movement of their limbs, they can use this to point to a communication board. So that's another means of communicating. Switches are important to trial, whether it be with their head, their arms, their elbow, their leg, their neck, whatever it may be, trialing different modalities to navigate is really important. The other thing that's important is giving them the cause and the effect. So if I just walk into the room and say, here, press the switch and I see what happens, they may not be motivated to press it, but if it turns on the TV or turns off music that they don't like, or turns on music that they do like, it's really important for us to give them that cause and effect. It's actually a reason I ask our therapists frequently to put patients in a power chair, even if I don't anticipate us getting one, I want them to feel the cause and effect if they can move their arm of either tilting themselves or being able to move through space. So again, really important to try these different things, different devices with this patient population, because once you know they're conscious, many of these patients are almost functionally locked into their body because of the other physical sequelae of their brain injury, and therefore we need to give them a way out. In addition to using these modalities, oh, here's just some more pictures of the head laser and ways that can be used to communicate. There's a push in the technological world to use something like brain-computer interface. I have not personally used this yet, but there's also the EEG biofeedback, lots of different ways these patients can demonstrate their consciousness using technology. And I think it's changing by the day, and we just need to stay on top of it to give these patients the chance to interact. And lastly, before I turn it over to Dr. Murtaugh for the interdisciplinary team, one of the things that I feel strongly about is that recommendation 2F talks about the decision to reduce the intensity of rehabilitation. If you are actively managing something with this patient, if we are saying, hey, I think they have subclinical seizures, or they really have a significant hydrocephalus that needs management, just because they've had rehab doesn't mean once that intervention has been performed, they need to move on. They may still need active rehab. So it's not appropriate if you're changing the medication, if you're ruling out different compounds to reduce the rehabilitation. You want to continue it while you're making these changes so you can look at the impact of those interventions on the rehabilitation. It's really important for these patients because I can't tell you how many times people have been underestimated and really it was putting a shunt in and they're a whole new person or removing one medication and all of a sudden everything changes. I have a patient right now who's been through three hospitals before getting to us. And I think because of the nature of these types of injuries, I think family members have a little bit more distrust in our community because they've been told all these things and then different things have happened. They've been told they're never going to wake up, they're never going to breathe on their own, they're never going to be anything more than what you see in this bed. And they actually do wake up and they do get off the ventilator and they do start moving around. So they question us and this family actually kind of latched onto their medications as a sense of control, something they had. And it took us a few weeks to get them to kind of release the medications to us to let us start manipulating and changing things. And today's Tuesday, yesterday I walked into the hospital and I evaluated the patient and she went from zero evidence of consciousness to nodding and shaking her head. And all we did was take off some of the medications that we felt were kind of cognitively limiting her. And the mom says to me, well, what do you think happened? Why is she different today? And it felt good to say, well, you let us finally change the medication. And that was really where we went with it. And so these patients don't have a lot to lose but they have a lot to gain. So I think when there is a lack of evidence out there, talking through the pros and cons and asking the family what they want, we kind of have a mentality of it doesn't hurt to try to the point that I had a family member once tell one of our physicians when they were going over the risk benefits of intrathecal baclofen pump. And someone said, one of the big risks is baclofen withdrawal with and could lead to death. And this conversation was happening in the hallway because obviously you don't want to talk in front of the patient. And the mother very loudly said, do you think the worst thing that could happen to my son right now is death? And that stuck with me. So remembering where these people are is very important. So again, behavioral assessment, there's a lot you can do. I don't expect physicians to be able to run these but that's where Dr. Murtaugh comes in with your entire treatment team coming together to help these patients. So with that, I will turn it over to her. Thank you. Let me pull up my section here. So I think that's a great lead-in to really putting this whole course and last week and what we've talked about tonight together and implement an interdisciplinary approach. And how can we look at those guideline recommendations in an interdisciplinary fashion and implement those guidelines to the best of our ability in our clinical practice, regardless if we're consulting in acute care, if we're in an LTAC, ARU post-acute care setting or skilled facility long-term care, how can we implement that interdisciplinary approach? So here are my objectives. We'll talk about the interdisciplinary team, how that can promote and facilitate more effective family counseling with that family and patient being the center of our care model. I don't have any disclosures. So what does physicians do you need to know? I think Dr. DiTomaso and Dr. O'Brien and Rosenbaum covered it very well over the last two nights, looking at confounds, medical management, when there's ambiguity in assessments, how can we try and decrease that uncertainty of what level of consciousness are they? Are they conscious? Have they emerged? And they just have so many different either medical or behavioral confounds that it's difficult to ascertain where they're at on the DOC spectrum. And so I think we've given you a lot of tools, maybe things that are new and you don't feel proficient at, but this is where your team comes in. You as a physician don't have to do it all and really rely on your other team members who may have more one-on-one bedside contact, especially in a rehabilitation setting with that patient. And knowing what questions to ask and to promote and facilitate those interventions and assessments through your team and that communication so you're getting all the pieces to the puzzle, not only to assist with diagnosis, but that prognostic piece too, and be able to counsel and answer the family's questions and eventually transition planning. We're always thinking about what is the next step for that patient? So interdisciplinary care, the guidelines, and it's a recommendation number one, so the emphasis is right there. Number one recommendation in the published paper is a multidisciplinary rehab team. These patients, once they're medically stable, need to get to that multidisciplinary team. To optimize the evaluation is what Dr. Rosenbaum and Dr. DeTomaso discussed, prognostication, medical management, and medical monitoring and rehabilitative care. The minimal competency recommendations. So Dr. DeTomaso was differentiating between the DOC guidelines, those evidence-based guidelines that can be implemented as well as in the minimal competency recommendations, which is really more focused on those centers and organizations that do have specialized DOC programming. And it's recommendation number five. Rehabilitation services in a DOC program should be provided by a multidisciplinary team of brain injury professionals. And then it goes on to list who those interdisciplinary team members should be. So right there, that kind of gives you that initial guide and you can start doing a checklist of the teams that you work with, who's all involved, who do I collaborate with, who is involved, are we missing certain disciplines that could really have benefit of being involved because of what their specialty is and what they could be doing with the patient. So for those visual learners, here's just another way to look at this with the patient and family in the middle, because we always want to be ensuring that we're giving consistent communication to the family and that everybody on the team is on the same page when communicating with the family and answering questions, especially as it relates to diagnosis and prognosis and assessment results. So again, take a look at this, you as the physician, you're kind of what I like to say, driving the bus, recommending orders, giving treatment recommendations, orders to eval and treat, but then look at the other disciplines that could and should be involved. You know, all your therapy disciplines and then asking the question again, what as physicians should you know? What do you need to know? Well, depending on your setting, what is the comfort level? Are you a specialized DOC program where your PT, OT, speech therapist, your neuropsychologist, nurse, respiratory therapist, case management, social worker, they see these patients every day and are very well versed in what they need to do within their discipline and collaborate with other disciplines with this patient population to develop the plan of care and keep that plan of care moving forward in an effective manner. Or do you have certain team members that maybe aren't as competent or knowledgeable about DOC and then how can you as a leader of the team promote increased education or knowledge base with this patient population? I think one of the number one things as a physician that you can do regardless of level of care, but I especially feel this is important if you're a PM&R physician consulting in an acute care or ICU is ensure those referrals for evaluation and treat for physical, occupational, speech therapy. Because so many times when I'm consulted on cases that may be looking to come into our facility and our DOC program, that's one of the first questions I'll ask. Their team or maybe our nurse liaison that's working on the referral, is therapy seeing them? And many times, unfortunately, the answer is no. That they don't think they're able to participate, they're not aware or aroused enough, so therapy hasn't seen them. Or if they are, they're going in and doing custodial or non-skilled interventions of just range of motion. I won't even get on my soapbox about that. But that's one of the first things that you as a physician can do if it hasn't already been done is there's no time like the present to get your other disciplines in there with eyes on the patient. And how can that interdisciplinary team collaborate? Well, they can collaborate in all those domains that the guidelines cover. Assessment and diagnosis, just as Dr. Rosenbaum and Dr. O'Brien highlighted with the CRSR and the IQBA, how can we be serially assessing these patients, not just one time, but multiple times over multiple days and weeks to really develop that trend line and identify what is that patient's baseline? We know there's gonna be inconsistencies, but can we identify a trend of progress or maybe they plateau or they're very consistent in having a certain score or one or two point difference, but then making sure that that is being communicated to you and communicated throughout the team, which in a post-acute care setting that may be a little bit more team oriented that can be easier versus either in acute care setting or maybe skilled or long-term care where there might not be that more focused team approach to make sure you as the physician are getting all the information that you need to continue to care for this patient. Management of confounds. Dr. G. Tomaso talked about this so many times. If it's spasticity, aphasia, apraxia, visual deficits, it's us as therapists, the OT, this PT, the speech therapists that are really specialized in identifying those compounds and being able to rule in and out certain compounds and be able to adjust assessment or implement IQBA that can identify potential behaviors that can be utilized to assess level of consciousness even if there's a multitude of behavioral confounds. I know in our team, especially with our serial assessment over weeks of rehabilitation, sometimes it's us through assessment that we're alerting our physician and our head physiatrist that, hey, something's off here. They've been consistently scoring 12, 13, 14 on their CRSR and now they're tanking. Is there something going on? So we might be able to alert the physician that there may be something medical going on. They may be brewing up a pneumonia or a UTI. Something medically has changed. If we see a significant change in score, especially a regression for a period of time where we know that's not the baseline or the norm for the patient. Care planning, some other questions to be asking yourself in the areas that you practice. Do you have team rounds? That's one of the venues where we can have the most team collaboration and discussion and our physician is in there with that team rounds and is getting all the information from all sides and what the team is observing and implementing with that patient. What do your team rounds look like? Is it just going over goals and have they met them or have they not? Or is it really getting into the discussion of the nuances of the patient and the inconsistencies, do they need an IQBA? Are we making progress with spasticity management? Oh, we're noticing consistently that, you know, this patient has the most movement in their foot and let's see if we can establish, you know, a communication avenue through switches using their feet. You know, so again, what does that team communication and collaboration look like? Team members may say, hey, I'm observing this behavior more consistently at this time of the day. And, you know, OPT may be saying, when I see them every day at three o'clock, you know, I'm not getting anything. You know, is that because of fatigue? Is that due to meds? Do we need to change things up to make that therapy session just as effective as another therapy session during the day? And then, you know, who is communicating with the family? You know, everybody's seeing the family, especially, you know, if they're there and present around the clock, and who is having that focused communication with the family, especially if they're asking tough questions as it relates to prognosis, transition of care. You know, as Dr. O'Brien was mentioning, you know, if they're making comments of, my loved one wouldn't want to live this way, or is this how it's going to be forever? You know, this is not what we signed up for, which can be a totally different lecture in and of itself about those ethical considerations with this patient population, especially if the DOC becomes a long-term chronic issue for that patient. But we're not going to go down that rabbit hole tonight. So again, assessment diagnosis, this has been covered very well by Dr. Rosenbaum and Dr. O'Brien. Again, highlighting the practice guideline recommendations 2A through C, talking about the CRSR. And that's a question as a physician that you can ask your team. Who on the team is completing, who has been trained, who's competent to complete the CRSR or any other DOC behavioral bedside assessment? Is it OT speech? Is it PT, neuropsychology, depending on the organization, it can be different disciplines depending on where it fits in their workflow and their knowledge base and expertise. And then you can ask the questions, how often are you doing it? What time of day? What are the results? So again, those are things as a physician that you can be asking and then promoting that practice and evidence-based practice in your team if it's not already happening. So what are the interdisciplinary interventions? Just as Dr. Rosen or Dr. O'Brien was talking about with IQBA, visual function, Dr. DiTomaso alluded to it with intensive mobilization to increase arousal and responsiveness. What are the interventions that your team is doing in those rehab sessions when they're at the bedside? How are they assessing arousal and awareness? Again, are they using a valid and reliable DOC assessment? Are they promoting arousal? As Dr. O'Brien discussed, were they doing an arousal protocol? I actually just consulted with a trauma team and an acute care team with a DOC patient. One, I asked them, okay, what assessments have you done? Because we're trying to identify behaviors to help advocate for this patient, this young woman who's in her 30s with three kids to get to rehab after a motorcycle accident and severe TBI. Okay, what are you doing? Well, we're doing range of motion. What assessments are you using? Well, what assessments are there? Have you used the CSR? We don't even know what that is. Okay, so some places we're starting from square one. But so, if they are doing certain assessments or interventions, what is the environment in which they're doing it? Are they promoting arousal? That's a question that I asked this team. They're like, well, we do everything in bed. Just all of us, if we laid down right now, would our level of arousal not drop? And so why would we expect anything different from our patient with a severe brain injury and disorders of consciousness? Their brain is already very low arousal. Why are we putting them in a position that the brain naturally goes into a lower state of arousal when you're supine or horizontal? Get that patient up. How are you promoting that arousal in order to get the best response from your patient and set them up for success? Are they assessing for compounds to consciousness? And so you as a physician doing your daily assessments with the patient will be able to start to identify spasticity, vision deficits, potential apraxias, and asking those questions of your team. Are you modifying or making adjustments or bringing the spasticity into consideration with the motor domain of the CRSR? Or do we have so many potential compounds do need to really drill down what the patient is able to do and move and implement an IQBA? So again, potential list of compounds. I think you've seen this over the last two nights frequently, but again, you can't behoove this point enough because this is where DOC care, in my opinion, can get really complicated. And if you don't have a great understanding of identifying and differentially diagnosing compounds, it can completely change your plan of care, how you transition plan, how you counsel the families and how you ultimately treat the patient and it'll impact your prognosis as you work with this patient. So I think in my clinical opinion, the best way to manage these compounds, and I think the guidelines and the minimal competency recommendations, that's why they recommend that multidisciplinary team because these patients we know can come with so many different factors that can mask consciousness. And we need to systematically try and identify those and remove them in the best way that we can to maximize the patient's function. And the best way to do that is through that interdisciplinary team because we're all coming to the patient, looking at them through a little bit different lens and paradigm depending on our training and our expertise. And so that's a huge benefit of that interdisciplinary team because you're gonna be able to look at that patient holistically, just not through the lens of medicine and HMPs and pharmacology, but also looking at it through function, vision, speech deficits, what's meaningful for the patient and those salient features. And then interdisciplinary care and prognosis. Prognosis is such a challenging concept with this patient population. We talked a little bit about it last week, that spaghetti model of the hurricane, like we're starting here and on day one or two post-injury, this thing could be going anywhere, but it's as we get further out from the date of injury, long-term prognosis becomes more and more clear, but that interdisciplinary team can help pull many pieces together to make that prognostic picture even more clear and put the puzzle together piece by piece. The more we do assessments, the more we manage confounds, we intensively mobilize, we establish a communication avenue, all those pieces that that team can bring and do with that patient, how successful or not that patient is in demonstrating consciousness and the consistency of those consciousness behaviors. And, oh my gosh, are they emerged and now they're able to start purposefully participating. Those are all important factors to know and identify through the trajectory of recovery because that helps put that prognostic puzzle together, which in my clinical experience is like the number one question families are asking. You know, what does the future hold? What do we need to plan for? Is this our forever? Are they going to get better? Because the unknown creates so much stress and anxiety for that family unit. So helping them plan and giving them somewhat more of a concrete answer because on day one, they either had, well, we don't know, or it's just not going to be good at all. And there's no hope, but yet they made the choice to pursue aggressive care because they themselves as a family had hope, you know, helping them plan and prepare and giving them some concrete information can really help manage that stress and anxiety and eliminate some of that ambiguity that the family has dealt with for many weeks or months. And so some of the questions as a team that you want to be asking as you counsel families, especially about prognosis, is what do families want to know? And that's different for each family. Do they want to know long-term prognosis? Do they want to know what things are going to look like in a week or in a month potentially? You know, do they want to plan everything from start to finish right away and have all their ducks in a row or looking a year ahead and the potential of long-term disability is just too much for them and they're not ready to hear some of that if that's the way the trajectory of recovery is going? How do they want it communicated? You know, we all have different learning styles and we know that families who are under severe duress, like they're only taking in maybe 10% of the information that you're giving. So you've got to give this information multiple, multiple times. And how do they want that communicated? Do they want to sit down one-on-one with the physician? I've come across so many families where like, myself as the OT and my treatment team, we're spending multiple hours with that patient and that family. But when it comes to this clinical information, they only really want to hear it from the physician. Like that holds the most weight for them as far as information or yes, have they built more of a rapport with the case manager, social worker or the whole team in general and it's gonna be more effective for them to sit down and have the information given to them in a family meeting format where everybody's there, providing the same information and really supporting that family as a team. Do they want it verbally? Do they want it written? Are there various resources on paper or online that you can give them to add to their understanding and knowledge base of what's happening with their loved one? And again, just like what I said, what members of the team are going to be providing that information. And sometimes that's team driven and who feels the most comfortable and who is the most competent in having those crucial conversations that at times can be stressful and challenging and very emotionally sensitive. Or is it the team as a whole or is the family dictating that, oh, I really only want to talk to the physician. What does the doctor have to say? So those are all questions that you can be asking your team or if you are working and treating within a team that you can be posing to your team. I wanna make sure I'm not going too long here. So interdisciplinary input communication will enhance ability to counsel families. I think we just talked about that. More information equals less ambiguity. Again, through the IQBA that Dr. O'Brien talked about, different assessments, identifying compounds, that's really what we're trying to eliminate. Is your loved one conscious and do they have the ability to participate and be a part of that family unit, return to their life roles in some way, shape or form, or is there still a big question mark where we don't know? So helping to identify those things so helping to eliminate those unknowns can certainly help with family counseling and putting that diagnosis and prognostic piece together. Also working as a team and having the right team members communicating and collaborating together with the DOC population can really help in effective transition and discharge planning. I know in our acute rehab hospital, we're always thinking of transition and discharge, like what's the next step after Madonna, even before they admit through our doors. As we're doing the pre-admission process, we're talking with the families, we're talking with the acute care teams, what are the potential discharge options so that we can start planning for that before they even come into the facility and how can we support the family in gaining the knowledge base and the skills to care for their loved one if they have long-term severe disability or if they just need that 24-hour support. As Dr. DiTomaso, this recovery, as he said, can go on for years and this patient population, we need to be patient and provide them the resources that they need to recover for years post-injury and how do we prepare the families for that. And so the interdisciplinary team can really play a crucial role in promoting successful transition, whether it's from acute care to an LTAC or an acute rehab from acute rehab to home or community or to another intermediate facility at a lower level of care. What is the most appropriate next step for that patient? And it requires team assessment intervention to see how the patient is responding. Unfortunately, I think, especially in the American healthcare model, insurance is a huge dictator of that, unfortunately, and payer source, but also having that as a piece of the puzzle of what does this plan of care look like and with the resources that we have available to us at this level of care, how can we best maximize that and prepare for the next level of care? So questions as a physician that you can be either asking your team or even posing to yourself or your other medical colleagues are, what are the therapists recommending from their treatment sessions? What are they seeing as far as progress? Or if it's a situation where there's a lack thereof, what are they recommending? What is medically appropriate for the next level of care? Do they have a trait? Do they still need ventilator support within a 24 hour period? Maybe it's just at night. Do they have indwelling devices that can only be managed at a certain level of care that a lower level of care wouldn't be proficient or comfortable in managing? What does the family want? Who's the decision maker? Oh my, that's a huge question. And your team should know that on day one, who is the surrogate for this patient? Is it guardian? Is it POA? Because they're gonna have to make these decisions for the patient. And so what is the family's goal and what do they want? And does the family understand different levels of care? You know, in your region, in your area, in the continuum of care that you have available to you and who do you refer to depending on where you practice, you know, not all levels of care as we know are the same and are not created equal. And do the families understand that the skilled facility or the long-term care facility that's maybe two miles away from their house and is really convenient for them won't know sikkim about DOC and your loved one may not get the care that they need even though it's really convenient, but yet here's a DOC program four hours away that is much more inconvenient for you but could definitely have a long lasting long-term benefit to your loved one in their overall recovery. So making sure they understand what they're gonna get at the level of care that they're deciding to go to or the level of care that is available to them depending on their resources for their payer source. And that just leads in, you know, what level of care do patient's resources support? You know, for example, for where I'm at in Nebraska, we admit many a patient from Missouri, but if they have Missouri Medicaid, straight Missouri Medicaid does not have resources that provide care at a skilled or outpatient level of care. So once you're out of inpatient rehab, you're done. Like we can't refer to home health, we can't refer to outpatient closer to home, there's no skilled benefit. So we know once they leave Madonna, they have to go home. And so what does that look like with our plan of care? Because we have no other option once they're done at Madonna. So those are some questions. And again, within your team, that's where your case manager and social worker come in to help navigate those very complicated waters. And overall, you know, big theme here as it comes to resources, our American healthcare system is not put together in a way that supports the DOC patient, especially the DOC patient that is going to require months and years of recovery and months and years of support or long-term care and resources. Our system just was not put together for that. And so it takes a lot of knowledge of the resources that are available and how to utilize them most effectively. And those are my references. So I will stop my share. Any questions on the interdisciplinary aspect of DOC care? You know, I get questions all the time, like, hey, especially from acute care teams, or individual clinicians, like I don't have access to A, B, and C, or, you know, I'm really passionate about severe TBI, but my PT counterpart would rather walk through fire than go into that ICU room. So, you know, be looking critically at where you practice, who are the counterparts that surround you and support you? What is their knowledge base? Because that may be where you have to start. If you're caring for these patients, you know, what is the knowledge base of your other disciplines that are working with that patient and giving you information? Because it's not helping you if you're not getting accurate information from your other team members. I would have two comments. I don't know if they're questions. Sure. One other team member that perhaps to consider being important might be peer counseling, whether it be family or patient, because families, I think, really respond probably more to somebody who's outside the system, who's gone through it and has something to offer, which talks to the importance, depending upon what state you're in, about the Brain Injury Alliance or the Brain Injury Association, and having a partnership with them potentially being significant. And then the one other comment I would make, you were talking obviously a lot about, for good reason, physician role. And I think you hinted at this, but I do think whether it's a physician who's seeing patients in acute care in the ICU or in a program such as yours, the advocacy role with insurance companies, because trying to get appropriate care like you're talking about, for even with private insurance, with patients who are severely disabled or have intermittent alertness and trying to convince a medical director of United or Aetna or whomever that they deserve the kind of program you're talking about is very difficult. So I think physicians have a strong, if not a primary role with that. Yeah, if you are a physician that's consulting, especially in acute care, if any of your other physician colleagues, whether that's trauma, neurocritical care, internal medicine, whomever is writing the recommendation, if anybody documents not appropriate for rehab, recommend long-term care or whatever, we're dead in the water before we even get started. If a physician documents that, game over. So just keep that in mind because maybe it's not you, if you're doing acute care PM&R consultation, maybe it's not you who's writing the recommendation depending on the organization set up, who's the attending physician, all that kind of stuff. But that's something to be aware of, or even therapists, oh my gosh, I can't tell you how many times I've come across acute therapy notes saying, recommend long-term care, patient not participating, patient not appropriate for rehab. And again, anytime that's documented, it's probably holds obviously more weight from a physician, but we just are then, it's a huge uphill battle if family wants to pursue like a specialty DOC program to get that third-party payer to pre-authorize that admission. Now I have had some luck in the recent past where the initial pre-auth is denied for whatever reason, looking at the notes, patients like a Rancho to whatever, they see that and they're like, oh, okay, we're not pre-authorizing that. Where I had sent that medical director of UHC or Nebraska Total Care, whatever, the guidelines and the minimal competency recommendations. And I highlight and I put in my appeal note, like here's the evidence supported by the AAN, supported by NIDILRR, ACRM, published in the Journal of Neurology, and here's recommendation number one, and this is why. And I have had some success with getting some denials overturned through that process. But those are really good points, especially too about the peer support for sure. Any other questions, comments before we move on to the case? Without further ado then, we will begin our case. So once again, we will start with some polls just to get a sense of where our audience is and should work the same as last time if you can just chime in. How familiar are you with the American Academy of Neurology, the American College of Rehab and Medicine? Do you implement the guidelines? You know, and a question I have, and if anyone wants to be brave and throw it in the chat, which I think for us who educate on this topic and the guidelines to various audiences, are there barriers within your organization for either not implementing at all or occasionally? You know, are there certain barriers? Because that's helpful for us to know as we continue to move on and focus on, you know, more stringent and focused intentional implementation, what are barriers to implementing? You know, one that we talk about frequently, especially with the authors of the guidelines, you know, is the one, what are the recommendations about functional MRI with, you know, ambiguous bedside assessment to identify potentially covert consciousness? You know, not everybody has functional MRI, you know, or will get authorization to do that or whatever. But if there's other recommendations that you still see significant barriers to implementation, that's super, that's very helpful for us to know, because, you know, this all looks good in research world and doing the meta-analysis and looking at the level of evidence and giving as high of level of recommendation as possible with the authors, but in the real world, can that efficiently be implemented? And just to quickly add to that, I had this experience actually this week where a patient came to us after doing an insurance appeal, because the physician at the hospital she was at prior to coming to us said they had a DOC program, but they were new. And so the insurance wanted to know why she had to move states if they had one. And the family member shared with us that, oh, we would want to be like that program even if we had more money. And now that the patient has been with us for several weeks, the family member asked us, well, I thought they meant like you had some sort of machine or some specific thing. And I think a lot of the care for this patient population doesn't have to do with fancy equipment or a thing. It's more of a mentality. And so I shared with that family member that if she ever speaks with that physician again to let her know it's not a money thing, it's really an investment in your staff and the mentality the staff have for treating this patient population. So just wanted to throw that out there because I think finances is frequently a barrier for a lot of us. And it's not just like fancy equipment, it's financially supporting your staff for the education or financially supporting whatever it may be to provide the care. But it was interesting to hear this family member report that. All right, so we'll move on now from the poll questions to our case report. So for those of you who weren't here last week or may not remember, our ambiguous patient is Michael Sutton, a 26 year old gentleman with a Caucasian graduate student studying engineering involved in a high-speed motor vehicle accident, a restrained single occupant driver. He had obvious loss of consciousness at the scene, and he was, GCS was 3T per EMS. In the emergency room, evaluation was significant again for 3T with bilateral dilated pupils with slow pupillary responses. Brain stem reflexes were present, and the toxicology report was positive for THC and alcohol. CT evaluation, as we talked about last time, was known for hemorrhagic contusions to the frontal and occipital lobes, diffuse cerebral edema, and multiple areas of interparenchymal hemorrhage, including near the corpus callosum and the great white junction. And here was a possible CT meeting those approximate criteria. On day five, sedation was removed, and the patient had no signs of consciousness. Evaluation with EEG showed diffuse slowing, rare epileptiform spikes, easy for me to say tonight. He was able to breathe spontaneously, and his team was told, the trauma team told his family there was poor prognosis. On day 11, however, he made a little progress, being able to open his eyes spontaneously and continuing eye-opening with an out-of-trigger for minutes at a time. PM&R evaluated the patient shortly after. The patient was opening his eyes spontaneously. He was not tracking. Intubation was ongoing, but he was breathing over the ventilator with frequent desaturations noted, however, no volitional movements. Medications are listed here. After this evaluation, unfortunately, as so often happens, the patient was lost to post-acute care without the specialty team that is emphasized in those guidelines, as Dr. O'Brien and Dr. Murtaugh mentioned. During this time, the family believes that he did try to communicate, although they were unable to explain why, and he eventually returns back to your setting, again, keeping that ambiguous, as we understand that this could happen at an LTACH, rehab, or SNF, four weeks from when you last saw him and approximately eight weeks from the date of injury. Okay, let's talk about the challenges of transferring within the post-acute care systems and how you can help to guide this from both Dr. Rosenbaum and Dr. O'Brien. So, you want, okay. I'm trying to be polite to each other here, I think. I get the ball rolling. I think I'm gonna jump off of what was just being discussed before with respect to the third-payer reimbursement. I think I might've mentioned in my talk, if I did, I apologize for repeating, I'll make it brief, about a patient who was trying to come to us from out of state. And one of my colleagues here, please shake your head if I already told this story. And she was already on the verge of emerging from a DOC at like day 22 post her injury. At the time, they were trying to get her to us. And the team there wanted her to get into rehab. They were advocating for her. The insurance was ultimately the major barrier, concluding that because she didn't get into a standard TBI rehab program, that that meant she was not a rehab candidate. And I think that one of the, there's a couple of issues, one being finding, even if you have the top-notch acute rehab setting, which would be the ideal place to transition the patient once medically stable, there's very few of those programs that are really dedicated to this longer-term recovery patient group. And with increased pressures on the hospital systems to reduce their length of stay in the hospital, there is understanding resistance or hesitancy to admit a patient that you know, especially because they're also medically complicated, is going to be a revolving door and also is unlikely to be discharged safely in that six-week timeline that magically, you know, we wanna be able to show from a hospital discharge point of view. I think the other issue is really about an all-or-none view of the guidelines and the minimal competency recommendations. And, you know, the challenge being trying to think of what we're recommending or think of the ideal setting as a place that checks off all of the boxes. We recognize that these programs don't really exist yet as they are. There are a few of them, obviously, but I think the majority of the country is really vacant of any kind of level of expertise. And if we're thinking that in order to move the needle, we need to create new programs and get payers to approve new programs, we're going to have a major uphill battle. And that is our long-term goal. But in the short term, I think we need to be creative about working with what we have. Most settings do have a multidisciplinary team. They don't necessarily work as a transdisciplinary team, meaning in a really integrated fashion, but the players are there. And how you can, you know, take advantage of that. And again, maybe navigating some of the politics of that changing the way of thinking for a physical therapist to get comfortable communicating with the speech therapist about what their treatment plan is or what interventions they're providing. But that's how we need to conceptualize the team if we're going to make this work. From my standpoint, I think one of the challenges we face is a lot of people think, well, how do you get into rehab after you've been home? Do you have to have a medically qualifying event? Do you have to have something go wrong to get in? But we have found that if someone is lost to care, whether they're at home, whether they're at a lower level of care, if the goals change, if there is something that you can argue that can be worked on, transitioning someone back into rehabilitation or back into a SNF setting that they have this team in can be done. And again, it's that advocacy piece that has been mentioned and the physician taking that ownership of advocating, here's where the patient is, here are my very specific goals for this patient, and here's where we're going to go. So it's not uncommon for our friend, Mr. Sutton, got lost to care. What if he has severe hydrocephalus? What if we need to shunt him and bring him in because now new goals have opened up or something that hasn't been caught, spasticity being managed and injections being done that open up different methods of movement or communication. So I do think educating people and others that you can readmit to rehabilitation with new goals, but being very clear on what your goals are, what you plan to achieve and articulating that to that payer source. And I do want to turn it over to a question to you guys, but before I do my one other jump on what Dr. O'Brien is saying, it goes back to the assessment piece. We can't necessarily create these programs, but if we can boost up the level of competence and expertise across care settings by doing trainings like this, then we improve the likelihood of having a staff member who actually is available on site in any given setting, whether it's an LTAC or a SNF setting, who does know this population and who is able to detect the change in consciousness that's necessary for that referral back to rehab, because ultimately it all starts with who's monitoring the patient in those other care settings and who is assessing them for the change in consciousness that would then require the follow-up question of, and then who's taking that information and counseling the family and guiding the family on how to access, you know, get back into that care system that Dr. O'Brien was describing. So I think that said, I'm curious to hear from you guys who are out there and who might be in settings who can give us some honest feedback, because I think part of this for us is also, as Dr. Mortag said, the implementation piece, and the bigger mission is to help this get implemented in the care environments. So for those of you, you guys are here because you understand and are interested and are seeing these patients, obviously, and also as physiatrists, I assume are most likely to be advocates along with us. And so we are preaching to the choir with respect to hopefully the belief that these patients can benefit from rehab. So can you share what the barriers besides insurance may be? Are there internal barriers with respect to beliefs of other professionals or timelines, time pressure to get a patient out in place or other things that we should be targeting as sources of an implementation mission? Or maybe you all can think about that and write thoughtful responses in the chat box while we continue with Mr. Sutton. Yeah, I think that will hopefully allow some opportunity for concrete discussion using his case. Okay, so Mr. Sutton comes into your rehabilitation service. You note on your initial evaluation, still no obvious volitional movement. He does still, however, open his eyes spontaneously. And based on feedback from staff members, as well as your own observation, there's questionable eye contact at this period. When you begin placing some consults, so this is typical within the rehabilitation. This is the team that you assemble as you see appropriate for Mr. Sutton's care. So I'm gonna turn it over to Brooke to talk a little bit about how from that very get-go you start to assemble this team and get everyone on the same page. Can you go back a slide quick? Yeah, so I mean, not anything new from what I was saying before, but again, this is where you want to do kind of your checklist, regardless of level of care, is who do you have available? Who is on your service? And taking the temperature of your team and your other disciplines of what is your level of knowledge and expertise? And what is your level of knowledge and comfort in working with this patient population? Because I think I may have said it last week, but I can talk from my personal experience as well as training a multitude of OTs and PTs and speech therapists that come through our organization. Nobody's getting this in school. Nobody's coming out of their training knowing IQBA, understanding the nuances and behavioral differences and presentations of coma, vegetative, minimally conscious states, not a clue of understanding what the potential long-term outcomes are. Unless you're living in this world day to day, it's hard to get this information because it's not part of the didactic work in the discipline training in OT, PT, speech, graduate programs. So that's a starting place. And then promoting that team either with education, getting them the information that they need in training, but also then helping them work collaboratively. Depending on the clinician and the organization, hopefully they have a paradigm of that collaboration versus I'm a PT and I'm only gonna work on sitting balance or I'm only gonna work on mobility and I'm an OT. So with this DOC patient who come hell or high water, I'm working on dressing with them, even though at this level, it's completely inappropriate and they're gonna be dependent with it, but thinking outside their discipline box and drilling it down to what is really appropriate with that patient. So I will get on my soapbox. I tell my clinicians that for this patient population, range of motion and going in and doing range of motion, whether they're in the bed, in the wheelchair, whatever, is not a skilled intervention. You should not be getting paid to do that with that patient. You can train a nurse aide, you can train the family, you could train a rehab assistant to do that, but look at all the other things that we've discussed over the last two nights that we can be doing with intensive mobilization, coma stim, spasticity management, again, the assessment piece, IQBA, that's what the skilled intervention is for this patient population. So if you've got clinicians that that is their go-to, there needs to be managing up of that clinical partner who is seeing your patient, because that's not gonna do anything, but maybe, maybe help mitigate a little bit of contracture, but there's so much more that you can be doing. And so, again, taking the temperature of your team and where they're at in their knowledge base with this population, because I think Dr. O'Brien hit the nail on the head. It's not, you don't need tons of money to have a quality program. It's really investing in your team and your staff to get them what they need, if they aren't at a level of proficiency that is needed. Now, just on that note, I'm curious to hear from Dr. DiTomaso, is there specific, you know, like bare minimum equipment that you would want in the rehab gym from a, say, standing frame or tilt table, or, you know, you mentioned the functional stim bikes. Like if, I know this is not really the minimum competency recommendations from a program point of view, but just from a conceptual, if there was gonna be a managing up and recommendations to include some kind of specialized equipment, what would be like the top three things you would recommend? Yeah, I think I could only probably come up with two off the top of my head, and that would be some kind of tilt table and then some kind of standing frame. Really, the best rehab can be done with those two things. The more toys you have, the better they can be used, obviously. But as everyone has been alluding to, this doesn't have to be fancy rehab. It just has to be hard work, right? You've got to get them up. You've got to get them moving. You know how to do that already with hemiplegic and paraplegic patients, most likely. This really isn't that different. If you have a $200,000 exoskeleton, great. You can have them walk down the hall. But if they, you can start with a tilt table and then progress to a standing frame, you've accomplished a lot of that already. Yeah. And I would probably add two more to that. Looking at what does your therapy department have accessible to them as far as augmentative communication, you know? And again, it doesn't have to be expensive. Switches are not expensive, just like what Dr. O'Brien showed. It's literally like Velfoam and Velcro, a pen light, you know, to look at eye gaze. It can be super simple, but yeah, communication, augmentative communication devices. And then just, you know, I see Shirley Ryan, Ability Lab, Shepherd. I would assume you guys have every type of wheelchair and specialty seating system under the sun available with pressure mapping and those things. But again, to have these patients up for a prolonged period of time to stimulate increased arousal, but keeping their skin safe and keeping them in a good functional position, you know, usually does require some specialty wheelchair seating and making sure that, you know, you have that available to you as well. Yeah, and it sounds like goals. So maybe I'm getting ahead. I don't remember exactly the order of the slides, but like what Brooke was saying with respect to the passive range of motion and what nurses' aides could do, I think a lot of maybe the obstacles, going back to that question earlier, also relates to not knowing how to set the goals and knowing what's appropriate to be setting for these patients. And there's some education needed around that as far as the payers too, who are expecting ambulation goals and toileting goals and self-care goals. And that's not necessarily reasonable. You know, if you're just thinking about bed mobility and some of those lower level things, it's more about understanding the types of activities to do with them more so than having to have all this high-tech fancy equipment. Question three. Hopefully this is a rather easy one. Based on what I've told you so far about Mr. Sutton, what would be the next most appropriate intervention to assess his current level of consciousness? So to recap, he moves his eyes, questionable tracking, no volitional movement, no obvious communication. Easy, 100% score, the JFK. Okay. Okay. So we were gonna ask our neuropsychologist now to comment a bit on some clinical pearls, perhaps of assessing behavior in someone as low level as Mr. Sutton at this point. Dr. O'Brien, it's your turn to go first. You know, for a patient like this, our institution would implement testing formally with the CRSR twice a week but given our specialized treatment team, whether you're a PT, whether you're an OT, whether you're a speech therapist, you're looking at evidence and signs of consciousness at all times. So you're looking for behavioral evidence of consciousness. So you can come to team rounds and talk to, do we need an IQBA? What are we seeing on CRSR? How do we wanna set this patient up for success? Are we requiring instructions from our physician to loosen something up that we think has volitional movement but is currently stuck with tone or spasticity? Can we get them in standing yet? Or do we need to serially cast those feet to get them to neutral so that they can put weight through their body? So in terms of the behavioral assessment, a lot of the discussions of those medical confounds should come first, but I would look to twice a week formal and a lot of informal touches in between, whether it be between myself, the speech therapist or any of the other therapists along with me. Yeah, the only thing I wanna add is just the note about the slide that spoke to the initial assessment that was a bedside evaluation where he did not appear to track visually or follow commands. And I just wanna reiterate the idea that therein lies the danger of the one-off assessments because had he been asked multiple commands using multiple domains, whether verbal or eye gaze or other things, and also assessed as Dr. O'Brien said in a standardized way over a couple of days or weeks, it would be a much more objective and accurate assessment than the informal assessments that typically occur, especially in the early ICU and acute care state. All right. So we do just that. We give him a formal assessment with the JFK Coma Recovery Scale, and he scores an A. The family insists that he is trying to talk or communicate in some way, and they notice that he is more consistently moving his left arm. However, your physical exam is largely unremarkable. Physical therapy, however, reports that he does increase his eye movements during, eye opening during standing, and speech confirms that they document or notice no obvious verbal communication. He does seem to have a bit of initial progress, but then he performs poorly for two days. On that day, he's very mildly hyperthermic after a vigorous occupational therapy session. You re-examine him and you find an average-sized man resting in bed, mildly diaphoretic. His eyes are closed, and he's non-responsive to verbal and tactile stimuli. There is a bit of a pungent urine-type odor within the room. Another question. What would be the lowest thing on your differential diagnosis at this point? One second while I get the question up. Go ahead and fire away. Based on that evaluation, and I'll go back one slide so you can see, is hyperthermic, diaphoretic, is non-responsive, and there's an unusual odor. And if we look at the work by Zhang and colleagues, of which Dr. O'Brien and I were lucky enough to participate, small bowel obstruction was relatively low in the distortive consciousness. All of the other issues, paroxysmal hyperactivity, heterotopic ossification, and urinary tract infections were much more common. Furthermore, the increased temperature along with the smell of urine, in my opinion, should lead you towards urinary tract infection as being high on the differential, not low. So from there, the next slide would be talking about medical complications to suppressing activity in consciousness. And I don't want to belabor this point, but any of the things that were on that differential can suppress the patient's ability to interact. So the fact that he was less interactive while having storming, or heterotopic ossification, or a UTI, for me is textbook disorders of consciousness management, and should be part of the thought process and evaluation of these patients. As we are getting a little late in the night, I'll move forward unless someone has a specific question. One thing I will, you know, Dr. Utmasi, you brought up in your presentation, I forget if it was today or last week, but kidney stones or bladder stones, also we found that it's something that kind of creeps in and can cause a huge change in this patient population, but isn't typically on our list of things we run through right off the bat. So just something I wanted to bring up because we found it to make a huge difference in patients' presentations, and it's not typically on the high end of our differential. All right, so you administer antibiotics and Mr. Sutton is now easier to stimulate and the therapist report renewed and improved. However, there seems to be differences between what the therapists report when he is standing versus when he's lying in bed. So you as a good physiatrist evaluate him in both settings. While in bed, he is mostly with his eyes closed. The eyes do open spontaneously, but not consistently for stimuli and his heart rate and blood pressure are well controlled. In the standing frame, however, his eyes seem to open more freely and he seems possibly to look around with the same questionable visual tracking that we mentioned earlier. Lastly, there are no real changes to his heart rate, but minimal orthostatic blood pressure changes in the standing. Brings us to poll question five. This increase in his eye opening, the mild orthostasis, when you evaluate this, it's most consistent with which of the following? And we made this one too easy. Yes, indeed, we were looking for increasing arousal, which is exactly what I was hoping to demonstrate here. I think that orthostatic hypotension was part of it. So you need to monitor that, of course. Positional dependent seizures do occur, but are relatively rare and would not typically present like this, although you need to keep a high index of suspicion, of course. An increased pain sensation is certainly concerning in this patient population. The fact that the blood pressure and heart rate stays around the same is reassuring, however. All right, so I think Dr. O'Brien, you were gonna speak about increasing arousal here. Sure. I think, so as a neuropsychologist, if I were walking to the hospital to see my patients, one of my hopes is that I get to see them up in their chair and they're not in bed. Again, the first thing I showed you, these patients in a hospital are frequently in bed. To be able to do a really good comprehensive assessment is more difficult in bed. So I can see them in their chair, but even the chair, especially a tilt in space chair, provides them this sense of kind of tilt and potentially decreased arousal. So getting to see these patients while in therapy, whether it's on a mat, whether it's on a tilt table, whether it's in standing frame, makes a very large difference. So when I train students who work with me, I say, if you're seeing this patient in one setting, you haven't done your job. I want you to go to PT. I want you to go to OT. I want you to follow the speech therapist outside when they have the patient outside. I want to see this patient in different positions because that can impact arousal. I also don't want you to go see them in the same therapy every day if that therapy always falls at the same time, given that different parts of the day, you may see the fluctuating arousal. So finding that pattern, finding what is helping, what is not helping, watching that the patient always seems to crash around this time, but their dose of methylphenidate comes at this time. If we move it up an hour, does that help that crash that you see? So monitoring that, or, you know what, let's give the gabapentin at night because it seems to be sedating. Don't give that during the day. Those types of things are important to observe and watch with the arousal. And again, the positioning makes a very large difference. We had a patient who was in a tilt-in-space wheelchair who, when tilted to 15 degrees, which is not that much, could not communicate. But if you got him above 15, so between 10 and 12, could actually turn his head just by coming up three degrees in the wheelchair, reduced gravity enough on the head to be able to turn it. And that could make all the difference in the world in someone being able to show that they're awake and alert. The other important thing about arousal is knowing what's arousal and what is eye-opening. Frequently, these patients may have difficulty opening their eyes and people say, oh, well, they're asleep. I have patients that will go through a full session answering behaviorally questions and their eyes look like they're closed, but I've observed and watched that their breathing pattern shows me that they're awake or the way they're moving. So we have patients that will manually tape, that will use transport tape and tape their eyelids open for them even just because arousal and eye-opening can dissociate. All right, Mr. Sutton continues his rehabilitation journey. His progress is perhaps slower than you would like. You decide to start a pharmacological intervention. However, you're looking for one that has the best support in the literature. Which agent would you choose? The right answer for this question is amantadine. Because it asks which medicine is best supported for neurological recovery. Which one has the best evidence? Amantadine has a large randomized controlled trial that supports it. The choice of pharmacological agents, however, in this population is very nuanced. If the situation was correct, I think any of the responses could have been phrased as correctly. I don't know if that's the case. I don't think we phrased it with which one had the best evidence. Because of course that is amantadine. But there is probably a time for any and every medicine you can imagine, which is neuropharmacological properties, to address these patients and their numerous issues. So I think the answer is amantadine. based on the Giacino and White study that's been referenced. We've added a mantidae, and the patient is now standing more frequently. He begins to improve his eye tracking. He's making more consistent oral movements, and he demonstrates increased movement of the left arm and the left leg. Based upon the progress of Mr. Sutton, can you estimate his current level of consciousness as below? OK. It seems like we have one person arguing for vegetative state, one for minimally conscious. There we go. I'll ask our neuropsychologist to weigh in on what are the key factors observed during this period that would give you a best estimate of consciousness? So I mean, for me, just in the turn-taking span of things, obviously, the eye tracking, I don't know if you want to go back just so that they can look at the previous screen, since somebody did indicate vegetative state. So if we're presuming at this point that the eye tracking, because we're administering the CRS, so that the eye tracking has been confirmed and has been scored on the CRS, and obviously, we don't have the cheat sheet up here, but if you remember the grid that I showed you, visual fixation and tracking both have little stars next to them indicating that they're minimally conscious behaviors. Also, there's some evidence to show that the presence of visual tracking is one of the first signs of emergence into minimally conscious state from vegetative state. And so from an assessment point of view, that's where the minimal conscious comes from. I do want to raise a little discussion point here, but I want to hear from Dr. O'Brien, any input she has as well. The only thing I would say is that this is, it's hard to say. So I frequently won't give the information of what I find until I've done adequate assessment. So if we've only seen one CRS or we've only seen one assessment, I may provide some generalities, but I frequently withhold providing a level of consciousness until I have more information to be able to provide it competently. And then I always say, at minimum. So no evidence doesn't mean it's not there. So we just may not have found it. So I think at minimum, we're looking at minimal consciousness, but that doesn't mean that the person is minimally conscious. It may mean that's all we've seen so far and that they're actually fully conscious. And I frequently provide this education to family members and always tell them, treat them as if they're fully conscious until we have any information that tells us otherwise. And just as we're going forward, keep in the back of your minds, looking at those behaviors, if there's any more information you would want at that stage, that might help indicate whether there is a higher level of consciousness present and whether you'd be recommending any further or different types of assessments to explore that further. Move forward in the interest of time. So you retest the patient with the JFK coma recovery scale revised, and he now demonstrates improvement to a new score of 12. The patient now demonstrates visual fixation on objects, and there are inconsistent reports of attempted but non-functional communication between the patient and the family and the patient and clinical team member. What would be potential caveats that would be influencing his attempts at communication? So Brooke, I'm going to let you do this. I just want to throw in something that I meant to talk about when I spoke and didn't have time, and it's relevant here based on the scoring. And that is that there's research on the CRS that even though we don't use the total score as translating to a diagnosis, there has been research showing that at that score of eight, that's sort of often the cutoff point for distinguishing between MCS and vegetative patients, and that that score of eight can distinguish between MCS and vegetative or unresponsive wakefulness in 93% of the cases. And a score over 10 provides very strong evidence of conscious awareness, although it is also the case that patients who don't score 10, the opposite does not hold true. So not achieving a 10 does not mean that the patient is not conscious, but if a patient passes the 10, then you do have strong evidence of consciousness there. So at this point, just sort of emphasizing the need to be exploring that communication potential. Yeah, so as far as the caveats for identifying potential communication with this patient, families reporting that they think the patient is trying to do some purposeful communication, I always think a misunderstanding about communication is that it has to be verbal, and that's not it at all. Again, these patients could be expressively aphasic, they could have oral motor apraxia, other confounds that could inhibit their ability to verbally communicate, but that doesn't mean that they can't utilize another system for communication, whether that's motoric, visual. And so being able to drill that down, asking the family, how do you think they're communicating, and then taking and using that lead to investigate further. And again, as Dr. O'Brien was talking earlier about utilizing various modalities, whether it's switches, eye gaze, really simple technologies to try and identify a communication avenue, because that can really open up the world for that patient, participating and engaging with the family, and also for us being able to more accurately identify their, have they emerged into full consciousness and even what's their level of cognition? They may be at a much higher level of cognitive functioning than we could have ever even imagined until we can establish that communication avenue. I think just on the flip side, adding in that there is a big jump there from being able to answer yes, no, or follow the saying yes on command and no on command to translating that yes, no response to communication. And that's often a sticking point for the patient's progress and sort of that key point in time to explore other modes of communication that may not rely on a yes, no response. We think yes, no is the easiest response, but sometimes it's not. Sometimes word recognition in a field of two visually is better, even though that seems to be a higher level response. All right, so Mr. Sitton now demonstrates the following progress. His physical therapy reports improved standing tolerance. Occupational therapy reports that he now engages with oral care. Speech reports that he is able to now trigger a swallow with stimulus. The family expresses concern, however, that the communication is still seeming to lack. At this point, you've observed increased oral motor activity with oral hygiene, increased oral motor activity with tactile and verbal stimulation, and persistent weakness on the right. Based on the family's concerns, you pull the team together to review everyone's reports. There seems to be rare, inconsistent, occasional vocalization of yes, but he is unable to consistently speak on command. Inconsistent reports of utilizing a thumbs up in response to personal questions, such as are you in pain? So how do we reconcile his progress in other domains with his perception of lack of progress with his communication? I think we've covered this a little bit, and in the interest of time, we'll try and make it short. Katie, if you want to respond quickly. Yeah, so real quickly, weakness on the right. We're thinking possibly a type of aphasia. We could look at the inconsistent thumbs up with an IQBA, and then look at other means of communication, whether it's a visual analog scale or anything else. In the interest of time, that's by Quick and Dirty. All right, so to finish up the case, based on the family's concerns, excuse me. So he's improved in a number of areas. His standing talents is better. He's engaged in basic hygiene, and he is communicating. However, he's obviously profoundly impaired cognitively. His insurance does not support further rehabilitation or other placement. The rehab team and the family schedule a family conference to review the progress and prepare for transition home. We'd like you to think about the key elements for a successful transition. What are the patient's needs, and what are going to be the demands of the family, and how is the patient best supported in his discharge to the community and the home? And with that, Dr. Murtaugh, I'll let you take it away. Yeah, I think I touched on this before, and again, in the interest of time. You know, I think one of the biggest things to think about is you can discharge these patients home. It's not out of the realm of possibility. It's a heavy lift and takes a lot of collaboration, family training, family engagement, thinking 10 steps ahead of home accessibility, those types of things, but it can be done. And it really is the best place for the patient. You know, there's been evidence that has shown patients who are at home living with disability have less comorbidities, secondary complications, and overall less mortality, decreased mortality than a patient who may go to an institution long-term or for a lifetime. But it definitely requires that team approach. And there's, you know, a ton of nuances, but again, we're running out of time, but it can be done, but thinking plan A, B, C, and D, and, you know, in tandem, working on various transition plans, depending on what the potential barriers are, what the family's able to do, what the resources are that are available to that patient and the family. And I just want to emphasize the role of family training. And much like you can argue that these patients can't actively participate in a rehab program, and I don't know what goals to set, and we would say, well, you know, there's all these mobility goals that we could be setting with them. In the back end of the program, family training are appropriate goals in transferring, in PROM, in positioning, in a number of domains, including the PEG management, trach cleaning. So allowing some time to be built in to facilitate that process. And I know that we have a representative from Shepherd here, and there was some great research that came out of Shepherd on a program of providing the family training and education to support transition back home. And their outcomes were actually better long-term outcomes than patients who were sent to long-term care settings. So there is some evidence to support. Home is not a death sentence, if anything. It's one of the better options that we have given the current care system. I think we're out of time. I don't know if, Brian, if you need to do an exit slide or announcement, but thank you all so much. We all had a lot of fun making this case and this presentation. Thank you for joining. Yes, thank you. Hope you guys had a good time. Take care. Thank you, everyone.

inpatient rehabilitation

cohesive teams

disorders of consciousness

assessment of consciousness

prevention of complications

early mobilization

pharmacological interventions

standardized assessments

family input

interdisciplinary approach

optimal care

American healthcare system

knowledge of available resources

peer counseling

transferring patients